MEDICAL AID AND GAP COVER

In South Africa, medical aid is a vital component of healthcare, providing access to a broad range of medical services, treatments, and specialists that are often not covered by the public healthcare system. Given the strain on public facilities and the long waiting times for non-emergency procedures, private medical aid ensures timely and quality care, improving health outcomes. However, medical aid plans often come with significant gaps in coverage, leading to out-of-pocket expenses for members, particularly for high-cost treatments, hospital stays, and specialist services. 

This is where Gap Cover becomes essential, as it helps bridge the shortfall between what medical aid pays and the actual costs, ensuring financial protection for unexpected medical expenses. 

With the National Health Insurance (NHI) proposal in South Africa, there are uncertainties surrounding how the private healthcare system, including medical aid and gap cover, will evolve. While the NHI aims to provide universal health coverage for all South Africans, it may impact the demand for private medical aid and gap cover, as it could reduce reliance on private healthcare for certain services. However, the transition to NHI is expected to be gradual, and many South Africans may continue to seek private healthcare options, keeping medical aid and gap cover relevant in the foreseeable future for supplementary and specialized care. 

Common Medical Aid Claims

• Chronic Related Conditions Resulting In Hospitalization
• Cardiovascular Conditions
• Oncology Diagnosis and Treatment Thereof
• Gastrointestinal Conditions and Scope Procedures
• Maternity Delivery

There are be many other reasons for individuals claiming on their medical aid and being hospitalized. The reality is, we never know WHEN or WHY we would require some sort of treatment whether it be in or out of hospital until it happens. As Private Healthcare plays a fundamental role in one’s financial planning and security journey, we ensure that education behind plan recommendation for you is outlaid and kept simple for your understanding with the necessary due diligence being taken into account.

Common Gap Cover Shortfalls

• Specialist Shortfalls - Majority of shortfalls are averaging around 300%/400% above and beyond the medical scheme rate currently
• Co-Payment requirements for certain procedures such as scopes, joint replacement and certain back and neck procedures.
• Oncology shortfall top-ups and first time cancer diagnosis 
• Casualty Benefit Claims

When considered and looked at in conjunction and understood properly, a well blended health plan choice can be structured with a gap cover policy, ultimately providing a well balanced setup which could have the benefit of cost saving and necessary benefits to safeguard against certain expenses.

Our Contracted Service Providers

Medical Aid

Bonitas

Bestmed

Discovery Health

Medihelp

Momentum Health

PPS

Gap Cover

Ambledown

Discovery Gap

Kaelo Health & Western Gap

Stratum Benefits

Turnberry